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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT �YNr 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Recely 'D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Oct 18 198 (Complete in Triplicate) ghn- td�e,�scribed.This application is p and the RuEYT",�rn f the San Joaquin Application is hereby made to the San JdaquiQfdinalHealth District for a nceNo. 549 for sewage o 1No 1862 forcwelltllurllpor stall IT/SERV! C pS LTH made in compliance with San Joaquin County �'+ Local Health District. Lot Size PM -- City .fob Address �. � Phone /r��s~ Address Owner's Name ! ` M,119M Phone License No. Address ESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ D NEW WELL OTHER C3F] E. TYPE OF WELL/PUMP: ( i/jQ SYSTEM REPAIR ❑ PRPP LINE { PUMP INSTALLATION IQ DISPOSAL FLD.r- 3 II SEWER LINES �� WELL��— PITS/SUMPS DISTANCE TO NEIAREST: .SEPTIC TANK --- AGRICULTURE WELL OTHER , - �OUNDATIQN _ - - __fa —CONS7RUCTfON-SPEC1FtEPTfON5 ` - •^"4 iTl PE OF.INELL PROSt'E1 ARDia. of Well Casing 4 �— �— TINTENDED USE ❑ Manteca Dia. of Well Excavation Specifications - ❑ industrial Open Bottom Type of Casing --- ❑ Gravel'Pack ❑ Tracy Type of Grout - 'Domestic/Private 171 Delta Depth of Grout Seal _ [_1 Public P Other S if e Seal installed by Approx. Depth l 1 Eastern State Work Done, 1 1 irrigation H.P. Repair Work Done EZ fpe of Pump �f �/' t Sealing Material (top 50'1 Well Destruction C1r VVeli Diameter �— — Filler Material (Below 50'1 Dlepth �. SEPTIC'l y available within 200 feet.) TYPE OF S rNEW INSTALLATION I"l REPAIRIADDITION l 1 DESTRUCTION l i INo septic system permitted if public sewer is Commercial— Other Installation will server✓. sidencee� Number of living units. _ — Number of bedrooms --- Water table depth h of 3 feet: No. Compartments I Character of soil to a dap Capacity-- SEPTIC TANK II Type/Mfg Method of Disposal PKG. TREATMENT PLT.jC7. Foundation -- property.Line 1 V Distance to nearest: Well I Total length i size LEACHING LINE ❑ No. & Length of lines Property Line i Foundation –�� FILTER BED 1 1]1 Distance to nearest: Well -- I _ Number Size SEEPAGE PITS l 1 Depth ��r•----flropert '— Line " _ -fc,rtdatiorr��w_ - - Ll--Distance•to-nearest:---"'WeN-_.�- _ - y. SUMPS 1._ DISPOSAL PONDS V ❑ r' v~ ' I hereby certify that have prepared this application and that�tha work wiI_br done in accordance with San Joaquin countyty ordinances, state favusan Y not rules and regulations of the San�oaquin l ocal Health"Dilowi g: I C� iANy that in the performance of the work for which this permit is issued. I shall ur Home owner or licensed agbnt's signature certifies the following: " r employ any P once of the work for which this per is issued, i shall employ persons subject to workman's compensa p per in such nner as to hecomeTubject to workman s compensation laws of California." Contractor's hiring or sub-contracting signature g. . certifies the followin 9 ce ify that in the performance w tion laws of Ca{ifYrnia." Tete drawing•'onIl reverse side. u dins Date: The applicant mu r Signed X � 3 FOR-bill 4iTTNENI' USE ONLY 1 ate t Area Application Accepted by — pate Date F.el'lnspaction by y Pit or Grout Inspection by 1 ❑ Tracy 835-6385 d Stk 466 1 Additional Comments: ❑ Lodi 369 3621 C3 Manteca 823 7104 ices 1601 E. Hazelton Ave., P.O. Box StIl CA 95201 678 Applicant - Retur all copies to: Environmental Health Permit/Saw , CK DATE PERMIT'NO. pECENED BY FEE AMOUNT DUE AMOUNT REMITTED GASH INV O -22 +.EH 1324 1HEV.5/x 51 EH 14-2d